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Abstract Background The Identifying Child Anxiety Through Schools-identification to intervention (iCATS-i2i) trial is being conducted to establish whether ‘screening and intervention’, consisting of usual school practice plus a pathway comprising screening, feedback and a brief parent-led online intervention (OSI: Online Support and Intervention for child anxiety), bring clinical and health economic benefits compared to usual school practice and assessment only — ‘usual school practice’, for children aged 8–9 years in the following: (1) the ‘target population’, who initially screen positive for anxiety problems according to a two-item parent-report child anxiety questionnaire — iCATS-2, and (2) the ‘total population’, comprising all children in participating classes. This article describes the detailed statistical analysis plan for the trial. Methods and design iCATS-i2i is a definitive, superiority, pragmatic, school-based cluster randomised controlled trial (with internal pilot), with two parallel groups. Schools are randomised 1:1 to receive either screening and intervention or usual school practice. This article describes the following: trial objectives and outcomes; statistical analysis principles, including detailed estimand information necessary for aligning trial objectives, conduct, analyses and interpretation when there are different analysis populations and outcome measures to be considered; and planned main analyses, sensitivity and additional analyses. Trial registration ClinicalTrials.gov ISRCTN76119074. Registered on 4 January 2022

Abstract Objective To understand the extent to which people who smoke, people who vape and nonsmokers would switch between smoking cigarettes and vaping in response to policies (price increases, restrictions on nicotine, places, and information on addictiveness and/or health risks) aimed at decreasing tobacco use by people who smoke and vaping by nonsmokers. Design A total of 525 adults aged 18 to 88 years completed a discrete choice survey of 16 choices between two smoking/vaping alternatives. Analysis was conducted using conditional logistic regression for the entire sample and stratified by nonsmokers, people who smoke, and people who vape. Results The results suggest that most people who vape also smoke. Nonsmokers were more favorable to vaping and were concerned about long-term health risks and cost associated with vaping. Marginal analysis suggests that price increases will have only modest success in moving people who smoke to start vaping or encouraging people who vape to vape rather than use cigarettes. Nonsmokers are not very sensitive to price changes but are sensitive to information about health impacts. Conclusions Findings indicate that increasing the price of cigarettes would lead to a limited increase in the probability of people who smoke switch to vaping. The study advances our understanding of the views of current nonsmokers toward cigarettes and vaping, suggesting that price increases and increased knowledge of addiction would likely deter nonsmokers from vaping. Changing the amount of nicotine associated with smoking would increase the probability of vaping slightly and have little impact on nonsmokers or vaping preferences, but the most significant change would come from increasing the perceptions of the risk of smoking.

The full-scale invasion of Ukraine caused an unprecedented number of refugees after 24 February 2022. To estimate the influence of this humanitarian disaster on the COVID-19 pandemic dynamics, the smoothed daily numbers of cases in Ukraine, the UK, Poland, Germany, the Republic of Moldova, and in the whole world were calculated and compared with values predicted by the generalized SIR model. In March 2022, the increase in the smoothed number of new cases in the UK, Germany, and worldwide was visible. A simple formula to estimate the effective reproduction number based on the smoothed accumulated numbers of cases is proposed. The results of calculations agree with the figures presented by John Hopkins University and demonstrate a short-term growth in the reproduction number in the UK, Poland, Germany, Moldova, and worldwide in March 2022.

The State University of New York (SUNY) – University of the West Indies (UWI) Health Research Consortium (HRC) was implemented in 2015 by the SUNY Global Health Institute (GHI) and the SUNY-UWI Center for Leadership and Sustainable Development. The goal was to advance public health in the Caribbean through collaborative research and education among faculty and students at SUNY and UWI. The Consortium is now a dynamic matrix addressing health priorities that were initially agreed upon with the Jamaica Ministry of Health and Wellness. The HRC has built a foundational matrix that is planning for cutting edge laboratory instrumentation, biomedical informatics system, seamless electronic medical records network, national laboratory data management system, and novel biotechnology (e.g., robotic surgery cluster). The SUNY-UWI partnership fills existing gaps through collaborative programs with the SUNY GHI that facilitate UWI faculty interactions with SUNY faculty and core resources and incubators that encourage collaborations while UWI infrastructure expands. The Health Research Consortium utilizes existing academic models at UWI and SUNY to promote collaboration, capacity building, and program implementation. Consortium teams develop sound business development models that foster sustained economic growth and form the pipeline for workforce development and career opportunities. The Caribbean diaspora and UWI alumni are engaged in working together on this effort. In addition, mentoring in K-12 and beyond is needed to create a vision for the next generations.

Abstract Background Systematically screening for child anxiety problems, and offering and delivering a brief, evidence-based intervention for children who are identified as likely to benefit would minimise common barriers that families experience in accessing treatment. We have developed a short parent-report child anxiety screening questionnaire, and procedures for administering screening questionnaires, sharing screening outcomes with families, and offering and delivering a brief parent-led online intervention (OSI: Online Support and Intervention for child anxiety) through schools. This trial aims to evaluate clinical and health economic outcomes for (1) children (aged 8–9) who screen positive for anxiety problems at baseline (target population) and (2) the wider population of all children in participating classes (total population) in schools randomly allocated to receive identification-to-intervention procedures and usual school practice (‘screening and intervention’), compared to assessment and usual school practice only (‘usual school practice’). Methods The trial design is a parallel-group, superiority cluster randomised controlled trial, with schools (clusters) randomised to ‘screening and intervention’ or ‘usual school practice’ arms in a 1:1 ratio stratified according to the level of deprivation within the school. We will recruit schools and participants in two phases (a pilot phase (Phase 1) and Phase 2), with progression criteria assessed prior to progressing to Phase 2. In total, the trial will recruit 80 primary/junior schools in England, and 398 children (199 per arm) who screen positive for anxiety problems at baseline (target population). In schools allocated to ‘screening and intervention’: (1) parents/carers will complete a brief parent-report child anxiety screening questionnaire (at baseline) and receive feedback on their child’s screening outcomes (after randomisation), (2) classes will receive a lesson on managing fears and worries and staff will be provided with information about the intervention and (3) parents/carers of children who screen positive for anxiety problems (target population) will be offered OSI. OSI will also be available for any other parents/carers of children in participating classes (total population) who request it. We will collect child-, parent- and teacher-report measures for the target population and total population at baseline (before randomisation), 4 months, 12 months and 24 months post-randomisation. The primary outcome will be the proportion of children who screen positive for anxiety problems at baseline (target population) who screen negative for anxiety problems 12 months post-randomisation. Discussion This trial will establish if systematic screening for child anxiety problems, sharing screening outcomes with families and delivering a brief parent-led online intervention through schools is effective and cost-effective. Trial registration ISRCTN registry ISRCTN76119074. Prospectively registered on 4.1.2022.

Geothermal energy is a renewable source of base-load power that is expected to play an important role in the transition to a low-carbon economy. In this article, we introduce a novel software application – named Geothermal Energy Impact Estimator – which computes the environmental impacts, including carbon emissions, of existing or future geothermal plants, using the Life Cycle Assessment (LCA) methodology. The software application is user-friendly and was designed to be used by geothermal companies and policy makers. We provide two specific use cases of the software application that represent existing plants in Iceland and in the UK.

The San Joaquin Valley (SJV) of California has been consistently identified as having one of the highest levels of air pollution in the US. Despite federal and state standards, the SJV has been in non-attainment status for daily PM _2.5 concentrations, extreme non-attainment for 8 hr O _3 levels, and attainment for NO _2 . An epidemiological time-stratified case-crossover design was used to estimate the relationship between exposure to NO _2 , O _3 , PM _2.5 and adverse health outcomes in asthma and upper respiratory infections (URIs). This study compared pollutant exposure effects for each case during limited time intervals and adjusted for seasonality. Elevated concentrations of three criteria outdoor air pollutants are associated with increased asthma and URI-related ED visits and hospitalizations in the SJV for all ages. NO _2 exposure increased the odds of having an ED visit by 2.4% in lag 1 (95% CI: 1.017, 1.031). Lags 2, 3, 4, 5, 7, 9, and 14 were statistically significant. O _3 modestly increased the odds of ED visits by 0.3% (95% CI:1.000, 1.006) after immediate exposure in the warm season. In the cold season, PM _2.5 estimates were significant for all lags except for lags 4 and 12. The two-week lag increased the odds by 28% (95% CI:1.218, 1.345) for ED visits, and 16.5% (95% CI:1.009, 1.345) increased the odds of being hospitalized after cumulative exposure to PM _2.5 . Findings suggest that SJV residents experience adverse health effects due to elevated exposure to NO _2 despite attainment of federal and state pollutant standards. This study provides new evidence about the effects of three criteria air pollutants and adverse health outcomes in the SJV region. The air quality regulatory and public health governing bodies should consider revisions to regional pollutant thresholds and local public health strategies to prevent adverse health outcomes during short and prolonged periods of air pollution exposure.

Abstract Background Anxiety disorders are common among primary-school aged children, but few affected children receive evidence-based treatment. Identifying and supporting children who experience anxiety problems through schools would address substantial treatment access barriers that families and school staff often face. We have worked with families and school staff to co-design procedures that incorporate screening, feedback for parents, and the offer of a brief intervention in primary schools. This study sets out to assess the feasibility of a subsequent school-based cluster randomised controlled trial to evaluate these procedures. Our objectives are to ensure our procedures for identifying and supporting children with anxiety difficulties through primary schools are acceptable and there are no negative impacts, to estimate recruitment and retention rates, and to identify any changes needed to study procedures or measures. Methods We will recruit six primary/junior schools in England (2 classes per school), and invite all children (aged 8–9) (n = 360) and their parent/carer and class teacher in participating classes to take part. Children, parents and class teachers will complete questionnaires at baseline and 12-week follow-up. Children who ‘screen positive’ on a 2-item parent-report child anxiety screen at baseline will be the target population (expected n = 43). Parents receive feedback on screening questionnaire responses, and where the child screens positive the family is offered support (OSI: Online Support and Intervention for child anxiety). OSI is a brief, parent-led online intervention, supported by short telephone sessions with a Children’s Wellbeing Practitioner. Participants’ experiences of study procedures will be assessed through qualitative interviews/discussion groups. Discussion Evidence-based procedures for identifying and supporting children with anxiety difficulties through primary schools would improve children’s access to timely, effective intervention for anxiety difficulties. Trial registration ISRCTN registry: ISRCTN30032471 . Retrospectively registered on 18 May 2021.

Geothermal energy is a renewable source of base-load power that is expected to play an important role in the transition to a low-carbon economy. In this article, we introduce a novel software application – named Geothermal Energy Impact Estimator – which computes the environmental impacts, including carbon emissions, of existing or future geothermal plants, using the Life Cycle Assessment (LCA) methodology. The software application is user-friendly and was designed to be used by geothermal companies and policy makers. We provide two specific use cases of the software application that represent existing plants in Iceland and in the UK.

Rationale & Objective: We sought to elicit patient preferences regarding the use of plasma exchange in antineutrophil cytoplasmic antibody-associated vasculitis (AAV) and its tradeoffs of risk of kidney failure and risk of serious infection. Study Design: Patient survey. Setting & Participants: The online survey was circulated to adults with AAV via kidney and vasculitis networks in Canada, the United Kingdom, and the United States. Outcomes: Respondents reviewed the estimated 1-year risks of kidney failure and serious infection in AAV with and without plasma exchange across 5 serum creatinine categories (150, 250, 350, 450, and 600 μmol/L). For each scenario, participants indicated whether or not they would choose plasma exchange. Analytical Approach: Responses were assessed with multilevel multivariable logistic regression models to identify predictors of respondent choice regarding treatment with plasma exchange. Results: The 470 respondents from the 13 countries (United States 61.7%, United Kingdom 20.0%, Canada 13.8%, and other countries 4.5%) had a mean age of 58.6 (SD 14.3) years, 70.2% women. Respondents were more likely to choose plasma exchange in scenarios at high risk of kidney failure and serious infection (creatinine level of 350 or 450 μmol/L) compared with lower risk scenarios or the highest risk scenario. However, 145 (30.9%) chose plasma exchange across all scenarios, whereas 80 (17.0%) declined plasma exchange across all scenarios. Respondents from the United Kingdom (OR, 2.61; 95% CI, 1.09-6.22) who received previous dialysis (OR, 2.70; 95% CI, 1.12-6.52) or received previous plasma exchange (OR, 5.62; 95% CI, 2.72-11.61) were more likely to choose plasma exchange, whereas older respondents (OR, 0.98; 95% CI, 0.96-0.99 per 1 year increase) were less likely. Limitations: Unclear generalizability to non–English-speaking, older, and less health literate adults, possible responder bias, survivor bias, lack of individualized risk assessments for kidney failure, and serious infection. Conclusions: Patients with AAV do not express a consistent choice for plasma exchange, which highlights the need for shared decision making.

Several independent comparisons indicate regenerative farming practices enhance the nutritional profiles of crops and livestock. Measurements from paired farms across the United States indicate differences in soil health and crop nutrient density between fields worked with conventional (synthetically-fertilized and herbicide-treated) or regenerative practices for 5 to 10 years. Specifically, regenerative farms that combined no-till, cover crops, and diverse rotations—a system known as Conservation Agriculture—produced crops with higher soil organic matter levels, soil health scores, and levels of certain vitamins, minerals, and phytochemicals. In addition, crops from two regenerative no-till vegetable farms, one in California and the other in Connecticut, had higher levels of phytochemicals than values reported previously from New York supermarkets. Moreover, a comparison of wheat from adjacent regenerative and conventional no-till fields in northern Oregon found a higher density of mineral micronutrients in the regenerative crop. Finally, a comparison of the unsaturated fatty acid profile of beef and pork raised on one of the regenerative farms to a regional health-promoting brand and conventional meat from local supermarkets, found higher levels of omega-3 fats and a more health-beneficial ratio of omega-6 to omega-3 fats. Despite small sample sizes, all three crop comparisons show differences in micronutrient and phytochemical concentrations that suggest soil health is an under appreciated influence on nutrient density, particularly for phytochemicals not conventionally considered nutrients but nonetheless relevant to chronic disease prevention. Likewise, regenerative grazing practices produced meat with a better fatty acid profile than conventional and regional health-promoting brands. Together these comparisons offer preliminary support for the conclusion that regenerative soil-building farming practices can enhance the nutritional profile of conventionally grown plant and animal foods.

The Asian hornet, Vespa velutina nigrithorax (Hymenoptera: Vespidae), is an invasive hornet that was accidentally introduced into Europe in 2004. It mainly preys on other invertebrates and arthropod species, and often targets honey bee (Apis mellifera) colonies. The introduction of these hornets may damage indigenous fauna and apiculture. Knowledge of V. velutina prey preference and the species composition of their diet is relatively limited. In this study, we assessed methodologies for the molecular identification of prey using dissected larvae from destroyed nests. Ten larval samples were taken from five nests in areas where the hornets had not yet established: two from the Channel Islands and three in the mainland UK. DNA was extracted from the gut contents and sequenced and analysed by metabarcoding with Oxford Nanopore Technologies’ Flongle and MinION devices. Numerous taxa were detected in each larval sample with the species composition varying by individual and by nest. Between 15 and 26 species were found per nest, with wasps (Vespula spp.), spiders, honey bees and blow flies being the most abundant taxa. These results demonstrate that metabarcoding larval gut contents can be used to study the Asian hornet diet and give a first snapshot of the prey items captured by V. v. nigrithorax in the UK. This method could be used for future large-scale testing of the gut contents of hornet nests, in order to provide a greater insight into the foraging behaviour of this predator across Europe and elsewhere.

Abstract Background As the demand for nursing home (NH) services increases, older adults and their families expect exceptional services. Neighbourhood Team Development (NTD) is a multi-component intervention designed to train team members (staff) in the implementation of resident-centered care in NH settings. A neighbourhood is a 32-resident home area within a NH. This paper presents the protocol used to implement and evaluate NTD. The evaluation aimed to 1) examine fidelity with which the NTD was implemented across NHs; 2) explore contextual factors associated with implementation and outcomes of the NTD; and 3) examine effects of NTD on residents, team members, family, and organizational outcomes, and the association between level of implementation fidelity and outcomes. Methods The study employed a repeated measure, mixed method design. NTD consisted of a 30-month standardised training and implementation plan to modify the physical environment, organize delivery and services and align staff members to promote inter-professional team collaboration and enhanced resident centeredness. Training was centred in each 32-resident neighbourhood or home area. Quantitative and qualitative data were collected with reliable and valid measures over the course of 3 years from residents (clinical outcomes, quality of life, satisfaction with care, perception of person centeredness, opportunities for social engagement), families (satisfaction with care for relative, person centeredness, relationship opportunities), team members (satisfaction with job, ability to provide person centered care, team relationships) and organizations (retention, turnover, staffing, events) in 6 NHs. Mixed models were used for the analysis. Discussion The advantages and limitations of the NTD intervention are described. The challenges in implementing and evaluating this multi-component intervention are discussed as related to the complexity of the NH environment. Trial registration ClinicalTrials.gov ID: NCT03415217 (January 30, 2018 – Retrospectively registered).

In recent years, the impact of respiratory disease resulting from Avian Metapneumovirus (aMPV) infection has been generally rising in the broiler industry in Europe. In this context, in order to investigate aMPV contribution to the clinical picture and the potential benefits of diversified vaccination strategies compared to nonvaccination policies, a longitudinal monitoring was performed, also evaluating Infectious Bronchitis Virus (IBV) presence. Broiler flocks located in Western France, where aMPV has already proven to be a health and productivity issue, were screened by RT-PCR on rhino-pharyngeal swabs, and the viruses were genetically characterized by sequence analysis. For a more comprehensive picture of aMPV molecular epidemiology and evolution in France, aMPV subtype B strains detected from 1985 to 1998 were sequenced and included in the analysis. The survey confirmed the detection of aMPV subtype B in commercial broiler flocks in France, together with a certain heterogeneity demonstrated by the circulation of more recent and historical French field strains. No IBV field strains were detected. The implementation and evaluation of different management choices and vaccine strategies suggests once again that immunization does not prevent infection but contributes greatly to the containment of the clinical manifestations.

Summary: Background: Public policy measures and clinical risk assessments relevant to COVID-19 need to be aided by risk prediction models that are rigorously developed and validated. We aimed to externally validate a risk prediction algorithm (QCovid) to estimate mortality outcomes from COVID-19 in adults in England. Methods: We did a population-based cohort study using the UK Office for National Statistics Public Health Linked Data Asset, a cohort of individuals aged 19–100 years, based on the 2011 census and linked to Hospital Episode Statistics, the General Practice Extraction Service data for pandemic planning and research, and radiotherapy and systemic chemotherapy records. The primary outcome was time to COVID-19 death, defined as confirmed or suspected COVID-19 death as per death certification. Two periods were used: (1) Jan 24 to April 30, 2020, and (2) May 1 to July 28, 2020. We assessed the performance of the QCovid algorithms using measures of discrimination and calibration. Using predicted 90-day risk of COVID-19 death, we calculated r2 values, Brier scores, and measures of discrimination and calibration with corresponding 95% CIs over the two time periods. Findings: We included 34 897 648 adults aged 19–100 years resident in England. 26 985 (0·08%) COVID-19 deaths occurred during the first period and 13 177 (0·04%) during the second. The algorithms had good discrimination and calibration in both periods. In the first period, they explained 77·1% (95% CI 76·9–77·4) of the variation in time to death in men and 76·3% (76·0–76·6) in women. The D statistic was 3·761 (3·732–3·789) for men and 3·671 (3·640–3·702) for women and Harrell's C was 0·935 (0·933–0·937) for men and 0·945 (0·943–0·947) for women. Similar results were obtained for the second time period. In the top 5% of patients with the highest predicted risks of death, the sensitivity for identifying deaths in the first period was 65·94% for men and 71·67% for women. Interpretation: The QCovid population-based risk algorithm performed well, showing high levels of discrimination for COVID-19 deaths in men and women for both time periods. QCovid has the potential to be dynamically updated as the pandemic evolves and, therefore, has potential use in guiding national policy. Funding: UK National Institute for Health Research.

ABSTRACT: Avian metapneumovirus (aMPV) is a viral pathogen that causes respiratory signs and drops in egg production most notably in turkeys but also affects chickens, ducks and other species. Four subgroups (aMPV-A, -B, -C and -D) have been characterized to date, which differ genetically, antigenically and in terms of geographic distribution and host range. Despite the rising awareness towards aMPV, many aspects of its epidemiology are still poorly understood.In this pilot study, a serological survey was carried out to assess the possible circulation of subgroups A, B, and C in intensively raised ducks in Northern Italy. A total of 220 sera from 10 Pekin duck flocks and one mallard flock were collected at slaughter and tested by subgroup-specific aMPV-A, B, and C indirect ELISA assays. None of the tested birds had been vaccinated against aMPV and no symptoms had been reported. No aMPV-A, B or C antibodies were detected in any bird of the Pekin duck flocks, whereas the entire mallard flock tested positive for aMPV-C antibodies. This is the first report of aMPV-C antibodies in ducks in Italy, where only aMPV-B has been reported to circulate in recent years. Further research efforts will be targeted towards the screening of a larger panel of samples, in the hope of obtaining positive samples from which full length genome sequences and infectious viruses can be isolated for virus characterization. Finally, the demonstration of aMPV-C specific antibodies in the serum of all sampled mallards indirectly suggests that this species is readily infected by aMPV-C and supports a possible role of wild anatids as a transmission vector of the virus.

Introduction Anxiety difficulties are among the most common mental health problems in childhood. Despite this, few children access evidence-based interventions, and school may be an ideal setting to improve children’s access to treatment. This article describes the design, methods and expected data collection of the Identifying Child Anxiety Through Schools – Identification to Intervention (iCATS i2i) study, which aims to develop acceptable school-based procedures to identify and support child anxiety difficulties.Methods and analysis iCATS i2i will use a mixed-methods approach to codesign and deliver a set of procedures—or ‘pathway’—to improve access to evidence-based intervention for child anxiety difficulties through primary schools in England. The study will consist of four stages, initially involving in-depth interviews with parents, children, school staff and stakeholders (stage 1) to inform the development of the pathway. The pathway will then be administered in two primary schools, including screening, feedback to parents and the offer of treatment where indicated (stage 2), with participating children, parents and school staff invited to provide feedback on their experience (stages 3 and 4). Data will be analysed using Template Analysis.Ethics and dissemination The iCATS i2i study was approved by the University of Oxford’s Research Ethics Committee (REF R64620/RE001). It is expected that this codesign study will lead on to a future feasibility study and, if indicated, a randomised controlled trial. The findings will be disseminated in several ways, including via lay summary report, publication in academic journals and presentation at conferences. By providing information on child, parent, school staff and other stakeholder’s experiences, we anticipate that the findings will inform the development of an acceptable evidence-based pathway for identification and intervention for children with anxiety difficulties in primary schools and may also inform broader approaches to screening for and treating youth mental health problems outside of clinics.

Melanaphis sacchari (Zehntner, 1897) and Melanaphis sorghi (Theobald, 1904) are major worldwide crop pests causing direct feeding damage on sorghum and transmitting viruses to sugarcane. It is common in the scientific literature to consider these two species as synonyms, referred to as the 'sugarcane aphid', although no formal study has validated this synonymy. In this study, based on the comparison of samples collected from their whole distribution area, we use both morphometric and molecular data to better characterize the discrimination between M. sacchari and M. sorghi. An unsupervised multivariate analysis of morphometric data clearly confirmed the separation of the two species. The best discriminating characters separating these species were length of the antenna processus terminalis relative to length of hind tibia, siphunculus or cauda. However, those criteria sometimes do not allow an unambiguous identification. Bayesian clustering based on microsatellite data delimited two clusters, which corresponded to the morphological species separation. The DNA sequencing of three nuclear and three mitochondrial regions revealed slight divergence between species. In particular, the COI barcode region proved to be uninformative for species separation because one haplotype is shared by both species. In contrast, one SNP located on the nuclear EF1-α gene was diagnostic for species separation. Based on morphological and molecular evidence, the invasive genotype damaging to sorghum in the US, Mexico and the Caribbean since 2013 is found to be M. sorghi.

Background: The coronavirus infectious disease-2019 (COVID-19) pandemic has led to an unprecedented shortage of healthcare resources, primarily personal protective equipment like surgical masks, and N95/filtering face piece type 2 (FFP2) respirators.Objective: Reuse of surgical masks and N95/FFP2 respirators may circumvent the supply chain constraints and thus overcome mass shortage. Methods, design, setting, and measurement: Herein, we tested the effects of dry- and moist-air controlled heating treatment on structure and chemical integrity, decontamination yield, and filtration performance of surgical masks and FFP2 respirators.Results: We found that treatment in a climate chamber at 70°C during 1 h with 75% humidity rate was adequate for enabling substantial decontamination of both respiratory viruses, oropharyngeal bacteria, and model animal coronaviuses, while maintaining a satisfying filtering capacity.Limitations: Further studies are now required to confirm the feasibility of the whole process during routine practice.Conclusion: Our findings provide compelling evidence for the recycling of pre-used surgical masks and N95/FFP2 respirators in case of imminent mass shortfall.

Abstract Background Long-term care (LTC) staffing practices are poorly understood as is their influence on quality of care. We examined the relationship between staffing characteristics and residents’ quality of care indicators at the unit level in LTC homes. Methods This cross-sectional study collected data from administrative records and resident assessments from July 2014 to June 2015 at 11 LTC homes in Ontario, Canada comprising of 55 units and 32 residents in each unit. The sample included 69 registered nurses, 183 licensed/registered practical nurses, 858 nursing assistants, and 2173 residents. Practice sensitive, risk-adjusted quality indicators were described individually, then combined to create a quality of care composite ranking per unit. A multilevel regression model was used to estimate the association between staffing characteristics and quality of care composite ranking scores. Results Nursing assistants provided the majority of direct care hours in LTC homes (76.5%). The delivery of nursing assistant care hours per resident per day was significantly associated with higher quality of resident care (p =

Abstract In classical bovine spongiform encephalopathy (C-BSE), an orally acquired prion disease of cattle, the ileal Peyer’s patch (IPP) represents the main entry port for the BSE agent. In earlier C-BSE pathogenesis studies, cattle at 4–6 months of age were orally challenged, while there are strong indications that the risk of infection is highest in young animals. In the present study, unweaned calves aged 4–6 weeks were orally challenged to determine the earliest time point at which newly formed PrPBSE and BSE infectivity are detectable in the IPP. For this purpose, calves were culled 1 week as well as 2, 4, 6 and 8 months post-infection (mpi) and IPPs were examined for BSE infectivity using a bovine PrP transgenic mouse bioassay, and for PrPBSE by immunohistochemistry (IHC) and protein misfolding cyclic amplification (PMCA) assays. For the first time, BSE prions were detected in the IPP as early as 2 mpi by transgenic mouse bioassay and PMCA and 4 mpi by IHC in the follicular dendritic cells (FDCs) of the IPP follicles. These data indicate that BSE prions propagate in the IPP of unweaned calves within 2 months of oral uptake of the agent.

Background: In many countries, concerns have arisen over the population using antibiotics without consulting a physician. This practice can place patients at risk and increase antibiotic resistance in the community. Objective: To evaluate individuals' preferences regarding the use of antibiotics. The study also assessed the likely effectiveness of interventions aimed at reducing inappropriate use of antibiotics. Methods: A discrete choice experiment (DCE) was conducted in Bogotá, Colombia. The attributes were determined by a systematic literature review and four focus group sessions. The DCE included nine factors – cost, time to get attention, level of symptoms, efficacy, safety, among others- and one label -using or not antibiotics. Data analysis was carried out using a generalized multinomial logit (GMNL) model. Marginal probabilities of different sets of attributes' levels were compared to estimate the likely effectiveness of interventions. Results: The survey was administered to 222 participants from diverse socioeconomic backgrounds. The results suggest that participants preferred not taking antibiotics and having a physician as an advisor, but the probability of inappropriate antibiotic use increased as the waiting time or the cost of receiving advice rose. The pharmacy was the preferred source of antibiotics, and participants chose the pharmacy worker (nonprofessional) as an advisor over the nurse on the phone. In the absence of any interventions aimed at reducing the use of antibiotics, approximately 47.3% of people would misuse antibiotics. This reduces to 26.5% when people perceive the efficacy of the antibiotics as low and the potential risks of self-medicating as high. An alternative model using a nursing service would likely lower inappropriate use of antibiotics. Conclusions: Even though people prefer not using antibiotics or visiting a physician in case of disease rather than self-medicating, current access conditions might discourage them from appropriately use antibiotics. The results suggest that interventions that informing people about the risks of self-medication and the low efficacy might significantly reduce inappropriate use of antibiotics. Our results also suggest that programs that empower other health professionals to provide access to antibiotics would likely further lower inappropriate use.

Understanding multilevel predictors of colorectal cancer (CRC) screening test modality can help inform screening program design and implementation. We used North Carolina Medicare, Medicaid, and private, commercially available, health plan insurance claims data from 2003 to 2008 to ascertain CRC test modality among people who received CRC screening around their 50th birthday, when guidelines recommend that screening should commence for normal risk individuals. We ascertained receipt of colonoscopy, fecal occult blood test (FOBT) and fecal immunochemical test (FIT) from billing codes. Person-level and county-level contextual variables were included in multilevel random intercepts models to understand predictors of CRC test modality, stratified by insurance type. Of 12,570 publicly-insured persons turning 50 during the study period who received CRC testing, 57% received colonoscopy, whereas 43% received FOBT/FIT, with significant regional variation. In multivariable models, females with public insurance had lower odds of colonoscopy than males (odds ratio [OR] = 0.68; p

Plain English summary The Experience Based Design (EBD) approach involves patients, staff and members of the public working together to improve a service. This paper evaluates the methods that are used to involve patients and members of the public in a project that aimed to improve the patient experience at Manchester Clinical Research Facility (MCRF). The aim was to explore what helps staff and members of the public to work well together. An evaluation questionnaire was used to get feedback from staff and public contributors. Questions included whether each person felt that they were able to shape the project; if they received enough training; whether they had enough time to complete each task; how well they thought the group worked together; and what could be improved. The findings showed that both staff and public contributors felt valued and that they were able to shape the project from the beginning. Training in EBD and research methodology, and providing enough time to complete each task helped to build relationships and increase confidence when contributing to the project. Personal benefits included a feeling of ownership over a worthwhile and rewarding project, increased awareness of public involvement and gaining new skills. The recommendations for successful involvement of patients and the public in EBD projects will hopefully be helpful for similar projects in the future. Abstract Background The Experience Based Design (EBD) approach promotes the effective involvement of patients and public contributors by enabling patients, public contributors and staff to co-design projects that aim to improve the patient experience. This approach allows patients and members of the public to have a role in shaping and improving current services. This paper aims to evaluate the EBD process from a public involvement perspective, exploring the barriers and facilitators to building successful working relationships. Methods An open-ended evaluation questionnaire was developed to gain feedback from staff and public contributors who co-produced an EBD project that aimed to improve the patient experience at Manchester CRF. Questions explored what worked well, how the project could be improved, and the benefits of being involved. Results Our findings highlight the importance of providing opportunities for staff, patients and members of the public to build relationships in order to feel confident in voicing their opinions. This can be achieved by training both staff and public contributors in EBD methodology to reduce any power imbalance that may exist. Negotiating adequate time to complete tasks and debate the best way forward also allows everyone to fully contribute to the project. Each individual felt that their contribution was valued and that they shaped the final action plan. Both public contributors and staff listed a number of personal benefits from their involvement in the project. This included a feeling of ownership over a worthwhile and rewarding project, increased awareness of public involvement in EBD projects and gaining new skills. Conclusion This evaluation provides recommendations for best practice for effectively involving public contributors in an EBD methodology. These findings aim to encourage a more consistent approach to EBD across organisations.

Hospital-acquired infections (HAIs) are a major concern to healthcare systems around the world. They are associated with significant morbidity and mortality, in addition to increased hospitalization costs. Recent outbreaks, including those caused by the Middle East respiratory syndrome coronavirus and Ebola virus, have highlighted the importance of infection control. Moreover, HAIs, especially those caused by multidrug-resistant Gram-negative rods, have become a top global priority. Although adequate approaches and guidelines have been in existence for many years and have often proven effective in some countries, the implementation of such approaches in low- and middle-income countries (LMICs) is often restricted due to limited resources and underdeveloped infrastructure. While evidence-based infection prevention and control (IPC) principles and practices are universal, studies are needed to evaluate simplified approaches that can be better adapted to LMIC needs, in order to guide IPC in practice. A group of experts from around the world attended a workshop held at the 17th International Congress on Infectious Diseases in Hyderabad, India in March 2016, to discuss the existing IPC practices in LMICs, and how best these can be improved within the local context.

In April 2014 and 2015, we noted localized alopecia (neck, forelimbs, and chest) and hyperpigmentation on two adult brown bears (Ursus arctos) captured in central-south Sweden for ecological studies under the Scandinavian Brown Bear Research Project. In spring 2015, a brown bear was shot because of human-wildlife conflict in the same region. This bear also had extensive alopecia and hyperpigmentation. Ectoparasites were collected from the affected skin areas in all three individuals and preserved in ethanol for identification. Based on morphological characteristics, the lice were identified as Trichodectes spp. and Trichodectes pinguis pinguis. To our knowledge, these are the first reported cases of chewing lice in free-ranging brown bears in Scandinavia.

Purpose: The aim of this paper is to outline the collaborative approach used to craft national learning standards for tertiary programs in the field of environment and sustainability in Australia. The field of environment and sustainability is broad and constituted by diverse stakeholders. As such, articulating a common set of learning standards presents challenges. Design/methodology/approach: The authors developed and used a staged collaborative curriculum design methodology to engage more than 250 stakeholders in tertiary environmental education, including discipline scholars, students, professional associations and employers and other environmental educators. The approach was adaptive, to ensure underrepresented stakeholders' perspectives were welcomed and recognised. The project was commissioned by the Australian Council of Environmental Deans and Directors (ACEDD) and funded by the Federal Government's Office for Learning and Teaching. Findings: The collaborative approach developed and used for this work facilitated an inclusive process that valued diversity of perspectives, rather than marginalise diversity in favour of a perspective representing a minimum level of agreement. This is reflected in the standards themselves, and is evidenced by participant feedback, piloting of the standards and their subsequent application at multiple universities. Achieving this required careful planning and facilitation, to ensure a democratisation of the stakeholder consultation process, and to build consensus in support of the standards. Endorsement by ACEDD formalised the standards' status. Originality/value: Collaborative curriculum design offered the opportunity to foster a shared sense of common purpose amongst diverse environmental education stakeholders. This approach to curriculum design is intensive and generative but uncommon and may be usefully adapted and applied in other contexts. The authors note one subsequent instance where the approach has been further developed and applied in transforming a generalist science program, suggesting the methodology used in this case may be applied across other contexts, albeit with appropriate adjustments: the authors offer it here in the spirit of supporting others in their own complex curriculum design challenges.

Introduction Preterm birth (birth

Successful transmission of Transmissible Mink Encephalopathy (TME) to cattle supports the bovine hypothesis for the still controversial origin of TME outbreaks. Human and primate susceptibility to classical Bovine Spongiform Encephalopathy (c-BSE) and the transmissibility of L-type BSE to macaques indicate a low cattle-to-primate species barrier. We therefore evaluated the zoonotic potential of cattle-adapted TME. In less than two years, this strain induced in cynomolgus macaques a neurological disease similar to L-BSE but distinct from c-BSE. TME derived from another donor species (raccoon) induced a similar disease with even shorter incubation periods. L-BSE and cattle-adapted TME were also transmissible to transgenic mice expressing human prion protein (PrP). Secondary transmissions to transgenic mice expressing bovine PrP maintained the features of the three tested bovine strains (cattle TME, c-BSE and L-BSE) regardless of intermediate host. Thus, TME is the third animal prion strain transmissible to both macaques and humanized transgenic mice, suggesting zoonotic potentials that should be considered in the risk analysis of animal prion diseases for human health. Moreover, the similarities between TME and L-BSE are highly suggestive of a link between these strains, and therefore the possible presence of L-BSE for many decades prior to its identification in USA and Europe.

The era of iatrogenic Creutzfeldt-Jakob disease (CJD) has nearly closed; only occasional cases with exceptionally long incubation periods are still appearing. The principal sources of these outbreaks are contaminated growth hormone (226 cases) and dura mater grafts (228 cases) derived from human cadavers with undiagnosed CJD infections; a small number of additional cases are caused by neurosurgical instrument contamination, corneal grafts, gonadotrophic hormone, and secondary infection with variant CJD transmitted by transfusion of blood products. No new sources of disease have been identified, and current practices, which combine improved recognition of potentially infected persons with new disinfection methods for fragile surgical instruments and biological products, should continue to minimize the risk for iatrogenic disease until a blood screening test for the detection of preclinical infection is validated for human use.

Donovan McGrowder1, Paul Brown21Department of Pathology, Faculty of Medical Sciences, The University of the West Indies, Mona, Kingston, Jamaica, West Indies; 2Department of Basic Medical Sciences, Faculty of Medical Sciences, The University of the West Indies, Mona, Kingston, Jamaica, West IndiesBackground: Leptospirosis is a zoonotic disease that is endemic in most Caribbean countries. This study examined the clinical presentations and laboratory findings in serologically confirmed cases of leptospirosis.Patients and methods: The medical records of all hospitalized patients with presumptive and confirmed leptospirosis between June 2005 and May 2006 at the University Hospital of the West Indies were retrospectively reviewed.Results: There were five serologically confirmed cases of leptospirosis. The mean age of patients with leptospirosis was 57.33 ± 8.21 years (range 41–67 years); all were men exposed to contaminated water or soil, and most cases were diagnosed in November. The most common symptoms were fever, myalgia, nausea, vomiting, headache, abdominal pain, and arthralgia. Increase in the mean serum creatinine concentration in patients with leptospirosis (439.40 ± 129.18 µmol/L) was significant when compared with that in the controls (87.86 ± 4.72 µmol/L; P = 0.005). Four of the five patients with leptospirosis showed evidence of hematuria. All patients with leptospirosis showed evidence of hyperbilirubinemia, which was mostly direct hyperbilirubinemia. The mean concentration of total bilirubin was 291.40 ± 52.33 µmol/L in patients with leptospirosis when compared with 9.83 ± 1.28 µmol/L in controls (P < 0.001). Thrombocytopenia (platelet count

Person-centered care (PCC) is fundamental for providing high-quality care in long-term care homes. This study aimed to evaluate the psychometric properties of an 11-item Team Member Perspectives of Person-Centered Care (TM-PCC) survey, adapted from White and colleagues (2008). In a cross-sectional study, 461 staff from four long-term care homes in Ontario, Canada, completed the TM-PCC. Construct validity and internal consistency of the TM-PCC were examined with a principal component analysis and Cronbach’s alpha coefficient. Findings revealed a three-component structure with factor 1, Supporting Social Relationships; factor 2, Familiarity with Residents’ Preferences; and factor 3, Meaningful Resident–Staff Relationships. The TM-PCC, as compared to the original survey, presented with less components (i.e., did not address Resident Autonomy, Personhood, Comfort, Work with Residents, Personal Environment, and Management Structure), yet included one new component (Meaningful Resident–Staff Relationships). The TM-PCC has a similar internal consistency (Cronbach’s alpha coefficient 0.82 vs. White et al. 0.74–0.91). The TM-PCC can be used to assess PCC from the staff’s perspective in long-term care homes.

Insufficient data exist on population-based trends in morbidity and mortality to determine the success of prevention strategies and improvements in health care delivery in stroke. The aim of this study was to determine trends in incidence and outcome (1-year mortality, 28-day case-fatality) in relation to management and risk factors for stroke in the multi-ethnic population of Auckland, New Zealand (NZ) over 30-years.Four stroke incidence population-based register studies were undertaken in adult residents (aged ≥15 years) of Auckland NZ in 1981-1982, 1991-1992, 2002-2003 and 2011-2012. All used standard World Health Organization (WHO) diagnostic criteria and multiple overlapping sources of case-ascertainment for hospitalised and non-hospitalised, fatal and non-fatal, new stroke events. Ethnicity was consistently self-identified into four major groups. Crude and age-adjusted (WHO world population standard) annual incidence and mortality with corresponding 95% confidence intervals (CI) were calculated per 100,000 people, assuming a Poisson distribution.5400 new stroke patients were registered in four 12 month recruitment phases over the 30-year study period; 79% were NZ/European, 6% Māori, 8% Pacific people, and 7% were of Asian or other origin. Overall stroke incidence and 1-year mortality decreased by 23% (95% CI 5%-31%) and 62% (95% CI 36%-86%), respectively, from 1981 to 2012. Whilst stroke incidence and mortality declined across all groups in NZ from 1991, Māori and Pacific groups had the slowest rate of decline and continue to experience stroke at a significantly younger age (mean ages 60 and 62 years, respectively) compared with NZ/Europeans (mean age 75 years). There was also a decline in 28-day stroke case fatality (overall by 14%, 95% CI 11%-17%) across all ethnic groups from 1981 to 2012. However, there were significant increases in the frequencies of pre-morbid hypertension, myocardial infarction, and diabetes mellitus, but a reduction in frequency of current smoking among stroke patients.In this unique temporal series of studies spanning 30 years, stroke incidence, early case-fatality and 1-year mortality have declined, but ethnic disparities in risk and outcome for stroke persisted suggesting that primary stroke prevention remains crucial to reducing the burden of this disease.

Strategies to investigate the possible existence of sporadic bovine spongiform encephalopathy (BSE) require systematic testing programs to identify cases in countries considered to have little or no risk of orally acquired disease or to detect a stable occurrence of atypical cases in countries in which orally acquired disease is disappearing. To achieve 95% statistical confidence that the prevalence for sporadic BSE is no greater than 1 per million (i.e., the annual incidence of sporadic Creutzfeldt-Jakob disease [CJD] in humans) would require negative tests in 3 million randomly selected older cattle. A link between BSE and sporadic CJD has been suggested on the basis of laboratory studies but is unsupported by epidemiologic observation. Such a link might yet be established by the discovery of a specific molecular marker or of particular combinations of trends over time of typical and atypical BSE and various subtypes of sporadic CJD, as their numbers are influenced by a continuation of current public health measures that exclude high-risk bovine tissues from the animal and human food chains.

The epidemic of bovine spongiform encephalopathy in the United Kingdom, which began in 1986 and has affected nearly 200,000 cattle, is waning to a conclusion, but leaves in its wake an outbreak of human Creutzfeldt-Jakob disease, most probably resulting from the consumption of beef products contaminated by central nervous system tissue. Although averaging only 10-15 cases a year since its first appearance in 1994, its future magnitude and geographic distribution (in countries that have imported infected British cattle or cattle products, or have endogenous BSE) cannot yet be predicted. The possibility that large numbers of apparently healthy persons might be incubating the disease raises concerns about iatrogenic transmissions through instrumentation (surgery and medical diagnostic procedures) and blood and organ donations. Government agencies in many countries continue to implement new measures to minimize this risk.of this rickettsia makes it available for use in serologic tests to determine its clinical spectrum, prevalence, and distribution.

BackgroundVariant Creutzfeldt-Jakob disease (vCJD) is a prion disease thought to be acquired by the consumption of prion-contaminated beef products. To date, over 200 cases have been identified around the world, but mainly in the United Kingdom. Three cases have been identified in the United States; however, these subjects were likely exposed to prion infection elsewhere. Here we report on the first of these subjects.Methodology/principal findingsNeuropathological and genetic examinations were carried out using standard procedures. We assessed the presence and characteristics of protease-resistant prion protein (PrP(res)) in brain and 23 other organs and tissues using immunoblots performed directly on total homogenate or following sodium phosphotungstate precipitation to increase PrP(res) detectability. The brain showed a lack of typical spongiform degeneration and had large plaques, likely stemming from the extensive neuronal loss caused by the long duration (32 months) of the disease. The PrP(res) found in the brain had the typical characteristics of the PrP(res) present in vCJD. In addition to the brain and other organs known to be prion positive in vCJD, such as the lymphoreticular system, pituitary and adrenal glands, and gastrointestinal tract, PrP(res) was also detected for the first time in the dura mater, liver, pancreas, kidney, ovary, uterus, and skin.Conclusions/significanceOur results indicate that the number of organs affected in vCJD is greater than previously realized and further underscore the risk of iatrogenic transmission in vCJD.

BACKGROUND: Human variant Creutzfeldt-Jakob Disease (vCJD) results from foodborne transmission of prions from slaughtered cattle with classical Bovine Spongiform Encephalopathy (cBSE). Atypical forms of BSE, which remain mostly asymptomatic in aging cattle, were recently identified at slaughterhouses throughout Europe and North America, raising a question about human susceptibility to these new prion strains. METHODOLOGY/PRINCIPAL FINDINGS: Brain homogenates from cattle with classical BSE and atypical (BASE) infections were inoculated intracerebrally into cynomolgus monkeys (Macacca fascicularis), a non-human primate model previously demonstrated to be susceptible to the original strain of cBSE. The resulting diseases were compared in terms of clinical signs, histology and biochemistry of the abnormal prion protein (PrPres). The single monkey infected with BASE had a shorter survival, and a different clinical evolution, histopathology, and prion protein (PrPres) pattern than was observed for either classical BSE or vCJD-inoculated animals. Also, the biochemical signature of PrPres in the BASE-inoculated animal was found to have a higher proteinase K sensitivity of the octa-repeat region. We found the same biochemical signature in three of four human patients with sporadic CJD and an MM type 2 PrP genotype who lived in the same country as the infected bovine. CONCLUSION/SIGNIFICANCE: Our results point to a possibly higher degree of pathogenicity of BASE than classical BSE in primates and also raise a question about a possible link to one uncommon subset of cases of apparently sporadic CJD. Thus, despite the waning epidemic of classical BSE, the occurrence of atypical strains should temper the urge to relax measures currently in place to protect public health from accidental contamination by BSE-contaminated products.